Patient Safety and Clinical Quality Program Summary The Patient Safety and Clinical Quality Program provides a framework for significant improvements to clinical quality in our public health system. Document type Policy Directive Document number PD2005_608 Publication date 26 July 2005 Author branch Clinical Excellence Commission Branch contact 02 9269 5500 Review date 01 December 2020 Policy manual Not applicable File number Previous reference N/A Status Review Functional group Clinical/Patient Services - Governance and Service Delivery, Incident Management Applies to Area Health Services/Chief Executive Governed Statutory Health Corporation, Board Governed Statutory Health Corporations, Affiliated Health Organisations, Public Health System Support Division, Community Health Centres, Dental Schools and Clinics, NSW Ambulance Service, Ministry of Health, Public Health Units, Public Hospitals Distributed to Public Health System, Community Health Centres, Dental Schools and Clinics, Divisions of General Practice, Health Associations Unions, Health Professional Associations and Related Organisations, NSW Ambulance Service, Ministry of Health, Public Health Units, Public Hospitals, Tertiary Education Institutes Audience Administrative;clerical;allied health;nursing. Policy Directive Secretary, NSW Health This Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for NSW Health and is a condition of subsidy for public health organisations.
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Patient Safety and Clinical Quality Program · 7. Clinical Governance Units 14 8. Incident management 15 9. Clinical Excellence Commission 16 10. Quality System Assessments (QSA)
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Patient Safety and Clinical Quality Program
Summary The Patient Safety and Clinical Quality Program provides a framework for significant improvements to clinical quality in our public health system.
Document type Policy Directive
Document number PD2005_608
Publication date 26 July 2005
Author branch Clinical Excellence Commission
Branch contact 02 9269 5500
Review date 01 December 2020
Policy manual Not applicable
File numberPrevious reference N/A
Status Review
Functional group Clinical/Patient Services - Governance and Service Delivery, Incident Management
Applies to Area Health Services/Chief Executive Governed Statutory Health Corporation, Board Governed Statutory Health Corporations, Affiliated Health Organisations, Public Health System Support Division, Community Health Centres, Dental Schools and Clinics, NSW Ambulance Service, Ministry of Health, Public Health Units, Public Hospitals
Distributed to Public Health System, Community Health Centres, Dental Schools and Clinics, Divisions of General Practice, Health Associations Unions, Health Professional Associations and Related Organisations, NSW Ambulance Service, Ministry of Health,Public Health Units, Public Hospitals, Tertiary Education Institutes
Secretary, NSW HealthThis Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for NSW Health and is a condition of subsidy for public health organisations.
Policy Directive
Ministry of Health, NSW73 Miller Street North Sydney NSW 2060
Locked Mail Bag 961 North Sydney NSW 2059Telephone (02) 9391 9000 Fax (02) 9391 9101
http://www.health.nsw.gov.au/policies/
spacespace
Patient Safety and Clinical Quality Programspace
Document Number PD2005_608
Publication date 26-Jul-2005
Functional Sub group Clinical/ Patient Services - Governance and Service DeliveryClinical/ Patient Services - Incident management
Summary The Patient Safety and Clinical Quality Program provides a framework forsignificant improvements to clinical quality in our public health system.
Applies to Area Health Services/Chief Executive Governed Statutory HealthCorporation, Board Governed Statutory Health Corporations, AffiliatedHealth Organisations, Public Health System Support Division, CommunityHealth Centres, Dental Schools and Clinics, NSW Ambulance Service,Ministry of Health, Public Health Units, Public Hospitals
Distributed to Public Health System, Community Health Centres, Dental Schools andClinics, Divisions of General Practice, Health Associations Unions, HealthProfessional Associations and Related Organisations, NSW AmbulanceService, Ministry of Health, Public Health Units, Public Hospitals, TertiaryEducation Institutes
Review date 26-Jul-2010
Policy Manual Not applicable
File No.
Previous reference N/A
Status Active
Director-GeneralspaceThis Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatoryfor NSW Health and is a condition of subsidy for public health organisations.
NSW Patient Safety and Clinical Quality Program
NSW Department of Health73 Miller StreetNorth SydneyNSW 2060Tel (02) 9391 9000Fax (02) 9391 9101www.health.nsw.gov.au
This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowledgement of the source and no commercial usage or sale. Reproduction for purposes other than those indicated above require written permission from the NSW Department of Health.
Establishing clinical indicators and performance informationThe Area Heath Service monitors and analyses performance information on quality and patient safety using
performance measures and clinical indicators included in strategic planning and business documents.
PD2005_585 A Framework for Managing the Quality of Health Services in NSW, issued 1999.
Monitoring and reporting performance informationThe Area Heath Service monitors, analyses and compares performance information on quality and patient safety
reported to Area executive and Advisory Council and strives to compete with the best performing facilities.
PD2005_585 A Framework for Managing the Quality of Health Services in NSW Issued 1999.
PD2005_604 Incident Management Policy, 2005.
Using performance information to improve patient carePerformance information is used by Area executive to evaluate and improve safety and patient care and to develop
strategies to reduce clinical and patient safety risks.
PD2005_585 A Framework for Managing the Quality of Health Services in NSW, issued 1999.
PD2005_604 Incident Management Policy, 2005.
Public awareness of quality and safety
The Area Health Service publicly reports information on patient safety activities and outcomes.
Patient safety performance
Health services perform to desired levels against targets for patient safety and performance is improving.
Standard �Health services have systems in place to monitor and review patient safety.
NSW Patient Safety and Clinical Quality Program NSW Health� NSW Patient Safety and Clinical Quality Program NSW Health�
Policy and standards
Standard �Health services have developed and implemented policies and procedures to ensurepatient safety and effective clinical governance.
Components
Minimum requirements
The Area Health Services develop, implement and review patient safety policies and protocols for incident
management, complaint management, complaints or concerns about clinicians, new interventions and correct patient/
site/procedure.
Implementation
Systems are in place to effectively disseminate, implement, review and update new policies and procedures on patient
safety to health facilities in the Area, including Departmental directives and safety alerts.
The Area policy on new interventions is consistent with Departmental guidelines and risk assessments are undertaken
before new procedures are introduced. An implementation plan is prepared for each new procedure introduced by the
Area.
PD 2005_333 (Circ 2003/84) Model Policy for the Safe Introduction of New Interventions, 2003.
Detailed policy review – correct patient/site/ procedure (Note: does not apply to the Ambulance Service)Health Services have developed an implementation plan to ensure all procedural teams comply with the Model Policy
on Correct Patient/Site/Procedure.
PD 2005_380 (Circ 2004/56) Correct Patient/Site/Procedure Model Policy, 2004.
Policy Directives and Related Documents
GL2005_061 NSW Health Better Practice Guidelines for Frontline Complaints Handling, 1998.
PD2005_585 A Framework for Managing the Quality of Health Services in NSW, NSW Health, 1999.
PD2005_586 Guideline on the management of complaints or concerns about a clinician, 2001.
GL2005_062 The Clinician’s Toolkit for Improving Patient Care, NSW Health 2002.
PD2005_337 (Circ 2003/88) Reportable Incident Briefs to the NSW Department of Health, 2003.
PD2005_404 (Circ 2004/82) NSW Health Incident Information Management System Policy, 2004.
NSW Health NSW Patient Safety and Clinical Quality Program �NSW Health NSW Patient Safety and Clinical Quality Program �
Policy and standards
Components
Notifying and assessing incidents
The Area Health Service supports a culture that facilitates incident reporting, the use of systems to notify and record
incidents using the Severity Assessment Code (SAC) matrix to identify matters requiring investigation, and ensures
incident reports are forwarded to relevant authorities within the required timeframe.
Investigating incidents
High-risk incidents are investigated in accordance with Departmental guidelines by a multidisciplinary team nominated
by the Area executive in a timely manner to analyse the incident, and to recommend key actions to minimise the risk
of recurrence.
Implementing recommendations
Recommendations arising from investigations are implemented in health facilities to improve patient safety. Incident
data is monitored and analysed to detect trends and determine whether system-wide improvements are needed.
Feedback on the outcome of investigations is provided to the Root Cause Analysis (RCA) team and the person who
reported the incident (where identified) and feedback is provided to staff on policy and procedural changes.
Incidents involving the death of a patient
Systems are in place to monitor deaths and determine whether changes in practice are needed to improve patient care.
PD2005_337 (Circ 2003/88) Reportable Incident Briefs to the NSW Department of Health, 2003.
PD2005_604 Incident Management Policy, 2005.
Standard �An incident management system is in place to effectively manage incidents that occur within health facilities and risk mitigation strategies are implemented to prevent their reoccurrence.
NSW Patient Safety and Clinical Quality Program NSW Health�0 NSW Patient Safety and Clinical Quality Program NSW Health�0
Policy and standards
Standard �Complaints management systems are in place and complaint information is used to improve patient care.
Components
Complaint monitoring and review
Responsibility for the timely management of complaints and feedback on the outcome of investigations to
complainants is assigned appropriately and systems are in place to record, monitor and review complaints.
Systems improvement
Complaint data are monitored, analysed to identify trends and to determine whether system-wide improvement
is needed to prevent recurrence. Processes are in place to address the systems issues identified by complaints, to
implement recommendations by health facilities and to ensure complaints information is reported to Departmental and
other relevant authorities.
Management of complaints or concerns about individualsComplaints or concerns against individuals are dealt with according to Departmental policy and within relevant
timeframes.
GL2005_061 NSW Health Better Practice Guidelines for Frontline Complaints Handling, 1998.
PD2005_586 Guideline on the management of complaints or concerns about a clinician, 2001.
NSW Health NSW Patient Safety and Clinical Quality Program ��NSW Health NSW Patient Safety and Clinical Quality Program ��
Policy and standards
ComponentsHealth services have developed an appropriate system of chart review.
Systems improvement
The results and recommendations of chart reviews and investigations are reported to management/Area executive and
staff, and the recommendations are implemented to effect system improvement.
GL2005_062 The Clinician’s Toolkit for Improving Patient Care, NSW Health 2002.
Standard �Systems are in place to periodically audit a quantum of medical records to assess core adverse events rates.
NSW Patient Safety and Clinical Quality Program NSW Health�� NSW Patient Safety and Clinical Quality Program NSW Health��
Policy and standards
Components
Performance review process
Health services have developed an appropriate system of performance review and meetings where clinical
management issues are adequately discussed and improvement action identified and documented.
GL2005_062 The Clinician’s Toolkit for Improving Patient Care, NSW Health 2002.
PD2005_500 Appointment of staff specialists, 2005.
PD2005_496 Appointment of visiting practitioners, 2005.
PD2005_497Delineation of clinical privileges for visiting practitioners and staff specialists, 2005.
PD2005_498 Performance review of visiting practitioners, 2005.
Systems/performance improvement
Performance review reports are forwarded to an appropriate delegate within the Area for action, matters requiring
further review are investigated, and feedback is provided to staff on any policy and procedural changes to effect
system improvement.
Standard �Performance review processes have been established to assist clinicians maintain best practice and improve patient care.
NSW Health NSW Patient Safety and Clinical Quality Program ��NSW Health NSW Patient Safety and Clinical Quality Program ��
Policy and standards
Components
Topic selection
Health services have developed a program of clinical practice audits that targets major care processes or practices
considered to be high risk.
Review process
People with relevant skills and knowledge conduct the audits. Audits are conducted in an efficient and effective
manner against pre-determined components or performance standards.
Systems improvement
The audits identify clinical management issues that need to be addressed to improve patient safety and quality care.
Audit results are reported to management/Area executive and feedback is provided to staff on policy and procedural
changes and ongoing monitoring of the effectiveness of systems changes is in place.
Standard �Audits of clinical practice are carried out and, where necessary, strategies forimproving practice are implemented.
NSW Patient Safety and Clinical Quality Program NSW Health��
� Clinical Governance Units�
The developing focus on the integrity and accountability
of health systems through clinical governance is integral
to improving the performance of health systems and
the enhancement of clinical care through analysis and
feedback. The concept of clinical governance integrates
clinical decision-making within an organisational
framework and requires clinicians and administrators
to take joint responsibility for the quality of clinical care
delivered by the organisation.
With the recent implementation of the health reforms,
clinical governance has been embedded in the new
Area Health Services (AHS) through the mandatory
requirement for all AHS to establish a consistent
organisational structure, including a Clinical Governance
Unit (CGU) as a direct report to the Chief Executive (CE).
Core functionsThe primary focus of the CGU can be summarised
as the risk management of patient safety and clinical
quality through implementation of the NSW Patient
Safety and Clinical Quality Program. The Program will be
implemented in collaboration with the Clinical Excellence
Commission (CEC), the Department and the CGU.
The CGU will build upon existing incident reporting
and investigation systems enhanced through
the implementation of the Incident Information
Management System (IIMS). Functions that will guide
the role of the CGU in 2004/05 are:
1 Structural establishment
2 Incident management
3 IIMS implementation
4 Complaints management
5 Death review
6 Continuous Quality Improvement (CQI) support
7 Communication training
8 Policy development
9 Clinician performance review
10 Reporting
11 External reports.
Other functions + Management of individual performance issues.
The establishment of clinician performance
review is a key part of the NSW Patient Safety
and Clinical Quality Program. The role of the CGU
will be to determine an appropriate performance
management framework for the health service,
in collaboration with the CEC, and be a source
of advice and expertise regarding due process for
those line managers.
+ Complaints management. The CGU will ensure a
single point of access for staff and the public to
register complaints and to take responsibility for
the management of serious complaints. The CGU
will lead the process of complaints management
but should not take over this function on behalf of
the health service.
+ Integrated risk management. Clinical risk
management is an integrated responsibility for
clinical operations and for the CGU. The CGU
will advise and support clinical operations in the
recognition and management of clinical risk. It
is not intended that the CGU assume global risk
management responsibility for the health service.
1 Draft NSW Clinical Governance Units Implementation Framework, 2004.
NSW Health NSW Patient Safety and Clinical Quality Program ��
��ncident management
A quality improvement framework requires routine
examination of all incidents that cause patient harm.
Most adverse events are not caused by a single,
individual action. They usually result from a chain of
events where inadequate safeguards and other systemic